Dual Coronary Artery Fistula from Left Anterior Descending and Right Coronary Artery to Pulmonary Trunk in a Patient with Myocardial Infarction—A Case Report

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How to cite this paper: Mishra, A., Ete, T., Dorjee, R., Jha, P.K., Malviya, A. and Kavi, G. (2016) Dual Coronary Artery Fistula from Left Anterior Descending and Right Coronary Artery to Pulmonary Trunk in a Patient with Myocardial Infarction—A Case Report. Open Access Library Journal, 3: e2590. http://dx.doi.org/10.4236/oalib.1102590

Dual Coronary Artery Fistula from Left

Anterior Descending and Right Coronary

Artery to Pulmonary Trunk in a Patient

with Myocardial Infarction—A Case Report

Animesh Mishra, Tony Ete, Rinchin Dorjee, Pravin Kumar Jha, Amit Malviya, Gaurav Kavi

Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

Abstract

Coronary artery fistulas (CAF) are precapillary communications between a coronary artery and a cardiac chamber or vessel. CAF have been described as the most common hemodynamically sig-nificant congenital coronary anomal. However, it remains a relatively uncommon clinical problem. Coronary fistulas originates slightly more common from the right than from the left coronary ar-tery, but the bilateral fistulas—those that originate from both coronary arteries—accounts for only 5% of total cases. These bilateral fistulas have a unique tendency to terminate in the pulmo-nary artery. More than half of the bilateral and only 17% of unilateral fistulas, terminates in this manner [1]. CAF are believed to be embryological remnants of sinusoidal connections between the lumens of the primitive tubular heart. This was first described by Maude Abbott in 1908 [2]. These ﬁstulas are usually discovered incidentally upon coronary angiography [3]. Their incidence in the overall population is reported about 0.002% and constitutes 0.13% of congenital cardiac lesion, however, they are found in 0.05% to 0.25% of patients who undergo coronary angiography. The most common site of drainage is the right ventricle seen in 41% of patients. Congenital CAFs usu-ally result from abnormal embryological development of the myocardial vascular system. Acquired CAFs are seen after trauma, endovascular procedures like coronary angiography, endomyocardial biopsy etcor cardiac transplantation. True fistulas of the circulatory system are characterized by an ectatic vascular segment that shows aberrant flow connecting two vascular territories gov-erned by large pressure differences. We report a case of double coronary to pulmonary artery fis-tula discovered during emergent coronary angiography for acute inferior wall ST-elevation myo-cardial infarction (STEMI) in a patient with no prior cardiac symptoms.

Keywords

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A. Mishra et al.

OALibJ | DOI:10.4236/oalib.1102590 2 July 2016 | Volume 3 | e2590

Subject Areas: Cardiology

1. Case

[image:2.595.212.413.264.455.2]

A 48-year-old man presented with acute onset chest pain in emergency. Electrocardiogram revealed ST segment elevation of >2 mm in leads II, III, aVF. Blood for troponin T was positive. The patient was diagnosed as a case of ST segment elevation inferior wall myocardial infarction. Dual Antiplatelets were started with other support-ing measures and the patient was transferred immediately to the catheterization laboratory. Coronary angiogra-phy showed significant stenoses of the left anterior descending (LAD), left circumflex (LCX) arteries and bor-derline lesion in mid right coronary artery (RCA). Moreover, it revealed the presence of 2 large coronary artery fistulas (CAF), one originating from distal part of left circumflex artery (Figure 1) and the other from proximal part of right coronary artery (Figure 2), both draining into the pulmonary trunk at 2 different, but close, entry

Figure 1. Right Anterior oblique caudal view showing fistula from left anterior descending artery to

pulmo-nary artery.

Figure 2. Right anterior oblique view showing fistula

[image:2.595.210.415.502.695.2]

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sites. Blood tests revealed Hb—12 gm/dl, total leucocyte count—13,800/cumm, platelet count—4.5 lakhs and creatine kinase levels of 1500 U/L along with elevation of CK-MB fraction. Renal function test and liver func-tion test were within normal limit. Transthoracic echocardiography (TTE) showed an ejecfunc-tion fracfunc-tion of 45%, hypokinesia in LAD territory, normal cardiac chamber dimensions and delayed relaxation abnormality with no evidence of pulmonary hypertension. After consideration of anatomy and extension of the remaining coronary stenoses and according to the wishes of the patient, the surgical treatment option (coronary bypass grafting and fistula ligation) was chosen. The clinical evolution was uneventful, and the patient was discharged on dual-antiplatelet therapy. He was on dual antiplatelets as in acute coronary syndrome it has a class 1 recommendation (Level of evidence A). Following discontinuation of dual-antiplatelet, the patient underwent coronary bypass grafting procedure for the LAD and LCX stenoses. A sequential LIMA (left internal mammary artery) grafting to LAD followed by LCX and ligation of the coronary artery fistulas at the ostium at the origin on the pulmo-nary artery was done after 6 weeks. The CABG was carried out on pump. No complications were observed in the post-operative phase and the patient was discharged 10 days after surgery to join a rehabilitation program.

2. Discussion

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A. Mishra et al.

distal embolization, aneurysm, dissection, rupture, pulmonary hypertension, premature atherosclerosis, myocar-dial ischemia [9]. Currently, percutaneous treatment is proposed as the first choice because it is less radical and entails a shorter period of hospitalization [10]. Surgery is reserved for cases of multiple fistulae, those affecting large branches during embolization of coils, or when the fistulous connection is narrow, restrictive and draining into a cardiac chamber [11]. Our patient presented with inferior wall myocardial infarction with significant le-sions in LAD, LCX and along with dual coronary artery fistula originating from distal part of left anterior de-scending artery and proximal part of right coronary artery. Patient was taken for coronary artery bypass grafting followed by ligation of fistula.

References

[1] Levin, D.C., Fellows, K.E. and Abrams, H.L. (1978) Hemodynamically Significant Primary Anomalies of the Coro-nary Arteries. Circulation, 58, 25. http://dx.doi.org/10.1161/01.CIR.58.1.25

[2] Schamroth, C. (2009) Coronary Artery Fistula. Journal of the American College of Cardiology, 53, 523. http://dx.doi.org/10.1016/j.jacc.2008.06.055

[3] Jerbi, S., Tarmiz, A., Fradi, S., et al. (2009) Coronary Artery Fistula: Case Report and Review of the Literature. An-nales de Cardiologie et d Angéiologie (Paris), 58, 236-239. http://dx.doi.org/10.1016/j.ancard.2008.05.014

[4] Urrutia-S, C.O., Falaschi, G., Ott, D.A. and Cooley, D.A. (1983) Surgical Management of 56 Patients with Congenital Coronary Artery Fistulas. Annals of Thoracic Surgery, 35, 300-307. http://dx.doi.org/10.1016/S0003-4975(10)61563-9 [5] Lerberg, D.B., Ogden, J.A., Zuberbuhler, J.R. and Bahnson, H.T. (1979) Anomalous Origin of the Right Coronary

Ar-tery from the Pulmonary ArAr-tery. Annals of Thoracic Surgery, 27, 87. http://dx.doi.org/10.1016/S0003-4975(10)62981-5

[6] Yamanaka, O. and Hobbs, R.E. (1990) Coronary Artery Anomalies in 126,595 Patients Undergoing Coronary Arte-riography. Catheterization and Cardiovascular Diagnosis, 21, 28-40. http://dx.doi.org/10.1002/ccd.1810210110

[7] Perloff, J.K. (1994) Congenital Coronary Artery Fistula. In: Perloff, J.K., Ed., The Clinical Recognition of Congenital Heart Disease, Saunders, Philadelphia, 562-580.

[8] Parga, J.R., Ikari, N.M., Bustamante, L.N., Rochitte, C.E., de Avila, L.F. and Oliveira, S.A. (2004) Case Report: MRI Evaluation of Congenital Coronary Artery Fistulas. The British Journal of Radiology, 77, 508-511.

http://dx.doi.org/10.1259/bjr/24835123

[9] Luo, L., Kebede, S., Wu, S. and Stouﬀer, G.A. (2006) Coronary Artery Fistulae. American Journal of the Medical Sci-ences, 332, 79-84. http://dx.doi.org/10.1097/00000441-200608000-00005

[10] Cheng, T.O. (1999) Management of Coronary Artery Fistulas: Percutaneous Transcatheter Embolization versus Surgi-cal Closure. Catheterization and Cardiovascular Interventions, 46, 151-152.

http://dx.doi.org/10.1002/(SICI)1522-726X(199902)46:2<151::AID-CCD7>3.0.CO;2-G

[11] Mavroudis, C., Backer, C.L., Rocchini, A.P., Muster, A.J. and Gevitz, M. (1997) Coronary Artery Fistulas in Infants and Children: A Surgical Review and Discussion of Coil Embolization. Annals of Thoracic Surgery, 63, 1235-1242. http://dx.doi.org/10.1016/S0003-4975(97)00251-8

Abbreviations

CAF, Coronary Artery Fistulas; LAD, Left Anterior Descending; LCA, Left Circumflex Artery; RCA, Right Coronary Artery;

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